Background: Till 2008, Jharkhand had only 12 designated first referral units (FRUs) at the district level and none of them were fully functional. This paper focuses on the processes, experiences and health system challenges in operationalizing FRUs in Jharkhand.

Methods: In an operations research, a pre and post assessment of designated FRUs in the study area was undertaken using standardized tool during March 2009 and February 2011.

Results: There was 33 % (04) increase in availability of obstetricians, surgeons and pathologists across the facilities. The availability of pediatrician was improved in 26% (02) facilities, while there were only 14 % (01) of anaesthetists across all the seven facilities. There was rise in recruitment of medical-officers and there were surplus in number for the designated FRUs. Only 29 % (02) of the facilities operated with a blood bank or blood storage unit. Parenteral-antibiotics and oxytocin availability remained stagnate at 86 % (06) and 57 % (04) respectively across the seven designated FRUs. Magnesium-sulphate availability had improved by 29 % across the facilities. There was rise in availability of Misoprostol in four (57%) facilities and dip in availability of Nifedepine in six (86 %) and lignocaine-hydrochloride in one (14 %). About four (58 %) of the facilities did not have maternal-newborn care equipments. At the end of the project, only three out of seven designated FRUs achieved operational status.

Conclusions: This piece of work on small scale generated evidence from Jharkhand made to think strategically to scale-up operationalization of FRUs. Lack of leadership, management, skilled human resources, infrastructure and medical supplies impeded operationalization of FRUs in Jharkhand. Access to comprehensive emergency obstetric and new-born care services (CEmONC) is remaining as a major issue.

/pdf/operationalizing-first-referral-units-frus-in-jharkhand-5r8c9dskim.pdf

Operationalizing First Referral Units (FRUs) in Jharkhand, India: Experiences from an operations research -

https://doi.org/10.1016/j.lansea.2022.100113

Hypertension control rate in India: systematic review and meta-analysis of population-level non-interventional studies, 2001–2022

Low density of formal care providers in rural India results in restricted and delayed access to standardized management of hypertension. Task-sharing with pharmacies, typically the first point of contact for rural populations, can bridge the gap in access to formal care and improve health outcomes. In this study, we implemented a hypertension care program involving task-sharing with twenty private pharmacies between November 2020 and April 2021 in two blocks of Bihar, India. Pharmacists conducted free hypertension screening, and a trained physician offered free consultations at the pharmacy. We calculated the number of subjects screened, initiated on treatment (enrolled) and the change in blood pressure using the data collected through the program application. Of the 3403 subjects screened at pharmacies, 1415 either reported having a history of hypertension or had elevated blood pressure during screening. Of these, 371 (26.22%) were enrolled in the program. Of these, 129 (34.8%) made at least one follow-up visit. For these subjects, the adjusted average difference in systolic and diastolic blood pressure between the screening and follow-up visits was -11.53 (-16.95 to -6.11, 95% CI) and -4.68 (-8.53 to -0.82, 95% CI) mmHg, respectively. The adjusted odds of blood pressure being under control in this group during follow-up visits compared to screening visit was 7.07 (1.29 to 12.85, 95% CI). Task-sharing with private pharmacies can lead to early detection and improved control of blood pressure in a resource-constrained setting. Additional strategies to increase patient screening and retention rates are needed to ensure sustained health benefits. 

/pdf/outcomes-of-a-hypertension-care-program-based-on-task-pk67il3x.pdf

Outcomes of a hypertension care program based on task-sharing with private pharmacies: a retrospective study from two blocks in rural India.

In India, the private sector provides 70% of the total outpatient medical care. This study describes the Mumbai Hypertension Project, which aimed to deliver a standard hypertension management package in private sector clinics situated in urban slums. The project was conducted in two wards (one "lean" and one "intensive") with 82 private providers in each. All hypertensive patients received free drug vouchers, baseline serum creatinine, adherence support, self-management counseling and follow-up calls. In the intensive-ward, project supported hub agents facilitated uptake of services. A total of 13,184 hypertensive patients were registered from January 2019 to February 2020. Baseline blood pressure (BP) control rates were higher in the intensive-ward (30%) compared with the lean-ward (13%). During the 14-month project period, 6752 (51%) patients followed-up, with participants in the intensive-ward more likely to follow-up (aOR: 2.31; p < 0.001). By project end, the 3-6-month cohort control rate changed little from baseline-29% for intensive ward and 14% for lean ward. Among those who followed up, proportion with controlled BP increased 13 percentage points in the intensive ward and 16 percentage points in the lean ward; median time to BP control was 97 days in the intensive-ward and 153 days in lean-ward (p < 0.001). Despite multiple quality-improvement interventions in Mumbai private sector clinics, loss to follow-up remained high, and BP control rates only improved in patients who followed up; but did not improve overall. Only with new systems to organize and incentivize patient follow-up will the Indian private sector contribute to achieving national hypertension control goals. 

/pdf/delivering-hypertension-care-in-private-sector-clinics-of-3eliveg3.pdf

Delivering hypertension care in private-sector clinics of urban slum areas of India: the Mumbai Hypertension Project

The National Rural Health Mission (NRHM) provides flexi-fund (a financing mechanism enabling pooling of money from fixed budget heads to be flexibly used as per local needs) to states and districts for paying for urgent but discreet expenses pertaining to maintenance of health infrastructure and provision of services at district, block and village level.

Decisions on use of such fund is to be made locally through various bodies/committees at district, block and village levels such as District Health Societies (DHS), Rogi Kalyan Samitis (RKS), Panchayati Raj Institutions (PRIs), Village Health and Sanitation Committees (VHSC) and village level health and Integrated Child Development Services (ICDS). Various policy documents and guidelines are available on use of flexi-fund.

Primarily, this fund is meant to ensure that health institutions at all the levels for healthcare services have readily available fund to overcome any bottlenecks that arise in the delivery of public health services. Amount of the flexi-find at various levels of healthcare services has been fixed (Table ​(Table11).



Table 1

Allocation of flexi-fund per year at various levels of healthcare services



As per the financial monitoring reports available from the state government, the utilisation of AMGs at primary health centres and community health centres level has remained around 50% in years 2008-09 and 2009-10. Utilisation of untied fund at health sub-centre level has been about 30% during the same years. Utilisation of untied fund at the village level by VHSCs has remained low.

We conducted this study to identify factors that impede or facilitate utilisation of flexi-fund at district and sub-district level. We aimed to use the findings of this study to developed revised operational guidelines on use of flexi-fund for consideration by state government.

/pdf/effective-utilisation-of-national-rural-health-mission-flexi-3xkc3679v8.pdf

Sapna Surendran

Papers

Delivering hypertension care in private-sector clinics of urban slum areas of India: the Mumbai Hypertension Project

Effective utilisation of National Rural Health Mission flexi-fund in Jharkhand: facilitators, barriers and options